The politics of childbirth

Overly medicalised? Starved of resources? Understaffed? Our story yesterday about one family's tragic experience of childbirth on the NHS has focused attention on maternity services in Britain. But are things really that bad? Sarah Boseley asks some of those on the frontline if they have faith in the system

The following correction was printed in the Guardian's Corrections and clarifications column, Monday March 28, 2005

The Albany Midwives are described in the feature below as being independent but they have asked us to point out that they are NHS midwives who are self-employed and self-managed, have a contract with the local healthcare trust and a caseload generated by local GPs in Peckham, south-east London.

Birth is scary. Nobody can completely prepare you for it, because the words they use don't translate to the physical sensations you experience when extraordinary primeval forces take over your body. And things can go wrong. Luckily it doesn't happen often, but on rare occasions the consequences are devastating.

Because of these two things, the vast majority of women in the UK opt to have their babies within what they believe is the comparative safety of an NHS hospital. But yesterday, a German couple living in the UK told the Guardian how their faith in our healthcare system has been completely destroyed following the disastrous birth, brief life and premature death of their second child.

Christoph Schwennicke and Ulrike Weidner's story was a devastating indictment of maternity care in the UK. They told of fatal delays after Ulrike arrived at the London hospital in the company of her independent midwife who was concerned because the contractions had unaccountably stopped. Eventually, the uterus ruptured and their son Jacob suffered severe brain damage. He died three months later.

The hospital has already recommended several changes in practice and says that lessons have been learned, but it is a disquieting tale that caused the couple to ask why the British tolerate their health service. "There's violence over foxhunting but no riots over the NHS," said Christoph.

This is not, broadly, a view that is recognised by those who work in the maternity service. There are flaws that can be picked at, they agree. There are serious shortages of midwives, particularly in expensive and busy London. Disasters will happen where you have human beings who make mistakes. It does not indicate something more seriously rotten in the state of the NHS. Maternity care is safe, they say.

But this story does, perhaps, shine a light on an issue that has been hidden in all the shouting in recent years over the medicalisation of birth. Way back in pre-NHS history, childbirth was a social event, albeit bloody, prolonged and painful, and it held major risks for the woman and the baby. Mortality rates were high.

The move to a system more closely focussed on hygiene, hospitals and doctors who could cut the baby out of the womb when necessary slashed the death rates. Women who went to GPs for a pregnancy test 20 years ago would probably not have been told that such a thing as a home birth was possible. But then came the counter-movement, backed by some women and some midwives, urging less medical intervention, caesareans only where necessary, induction as late as possible, an end to episiotomy. Even now, only 2% of women, on average, give birth at home, but in pockets of Devon the rate is in double figures and, astonishingly, the Albany group of independent midwives in Peckham, south London, has a home birth rate of 43%.

Meanwhile, back on the wards, amid all the hollering for less medical intervention it has been overlooked that when a birth is going wrong, when the midwife seeks the help of an obstetrician, the only one around is likely to be a registrar - a junior doctor, whose consultant is supervising at the end of a telephone if required.

In the noise and fury of the battle over philosophies of childbirth, is it possible that more practical questions have been overlooked?

"One of the things that should be debated is the level of consultant obstetric care you should be able to expect," says Mary Newburn, head of policy research at the National Childbirth Trust. The Royal College of Obstetricians and Gynaecologists has set a standard for consultant cover - at 40 hours a week. Yet babies do not keep office hours.

"What is shocking is that we haven't traditionally prioritised the availability of consultants to provide care for women in labour," Newburn says. The issue has been obscured by what she calls "the politics of childbirth". Does the presence of a consultant obstetrician, rather than a junior, on the labour ward lead to more interventions? Does the caesarean rate go up?

Interestingly, Newburn, whose organisation is at the forefront of the fight for more natural childbirth, says no. A senior, really experienced consultant is less likely to get out the scalpel and the gloves. He or she has the confidence to allow the woman to get as far as she can in a natural delivery. "What is important is that they are obstetricians who are women-centred and value keeping labour natural when it can be natural. But they are there to intervene swiftly and safely when it is needed."

Richard Warren, honorary secretary of the Royal College of Obstetricians and Gynaecologists, says they recognise the need for more consultant cover in the labour ward. "Our drive has already secured 40 hours in most units in the country," he says. They are now working towards 60 hours in cities and even full cover in the busiest maternity units.

But that will take more obstetricians. The numbers need to rise from about 1,400 to between 2,000 and 2,500, he says. If there is one thing everybody agrees on, it is that we are short of the staff we need in our maternity service, although the gaps vary around the country. Obstetricians have not been a priority for primary care trusts, who hold the purse strings and commission hospital services for their community, because the political pressure is on bringing down waiting lists and cutting cancer deaths.

Meanwhile, Britain's midwife shortage has been going on for so long it has almost become a cliche. Sue Macdonald, education and research manager at the Royal College of Midwives and a midwife herself, dates it to the 1990s when there were cuts in nurses as well as her own profession. "We're kind of having to increase our numbers on the back of that," she says. "We started with a deficit years ago."

The RCM says 10,000 more midwives are needed by the NHS, and the government agrees. It has a target of 2009 to get there. But although the Department of Health says it recruited 1,556 between 1997 and 2003, very many work part time. The real increase comes to just 391 in whole-time equivalents.

What this means to a woman in labour is that in some hospitals she will not get the one-to-one care which is so important for her wellbeing, that individual attention from a woman who knows all about it and will help her through the hard parts, when she thinks she can't go on. It's important physically, psychologically and emotionally. An expectant mother with one-to-one care is less likely to end up with a forceps delivery or, indeed, a caesarean.

Midwives want this too. Research by the well-respected academic Mavis Kirkham shows that midwives are more likely to stay in their jobs if they are part of a group of midwives responsible for a group of women, advising on pregnancy, educating them about labour, taking them to hospital and helping them through it. The ones who leave the profession are those dealing with what is thrown at them on every shift. "It was a fantastic experience, but I couldn't carry on working at that pace," says one midwife who moved back home to Northern Ireland four years ago from London. "By the time I finished my training I had to jump in the deep end because I was one of the most senior people there." There were always more senior people to supervise, but the pace in a hospital short of staff, she says, was untenable.

And the impact of all this, unsurprisingly, is felt by the women in labour. Although many say they had a good birth and a fine experience, "what happens to women in hospital often isn't very nice," says Miranda Dodwell of Birthchoice, which advises women on their options for delivery. They hear of other women's bad experiences and become frightened, she believes. She doesn't think more women are choosing caesareans to keep their figures; she thinks it's caused by fear. "I think women are now quite seriously thinking about what's going to happen to them when they go into hospital," she says. And on reflection they would rather have surgery, with its inherent risks, than face the feared hours of labour.

Mary Newburn says it's very hard to know what sort of experience of childbirth women are having. The last proper research was by the Audit Commission in the 90s. "It's terribly difficult to get a comprehensive picture because the NHS is so massive," she says. It's certainly hugely variable around the country - the widely differing caesarean rates and numbers of normal births give that away.

"We usually find that most people are having what appears to be a reasonable quality of care," says Newburn, "but it is quite possible to overlook quite substantial minorities who might be having poor quality care, and a smaller proportion who are having, quite frankly, unacceptably low levels of care."

Christoph Scwennicke and Ulrike Weidner believe they fall squarely into the last category. There will be others whose babies have survived without damage. Yet others will have had exemplary experiences of NHS deliveries. But until childbirth has a higher priority in an NHS focused, probably correctly, on the sick, just how much poor maternity care there is, and how much good, is pretty much anyone's guess.

· What are your experiences of NHS delivery services? We would welcome your feedback, good or bad. Email g2@guardian.co.uk

Europe's poor relation? How they do it abroad

France

In highly medicalised France, whose health service has been ranked the best in the world by the World Health Organisation, pregnancy ranks as a serious (if common) illness. From the first month to the ninth, seven doctor's consultations and three scans are obligatory. Many women see their doctor more often: once a month for the first six months and every fortnight for the final three.

In France's public-private health system, most people who have a job benefit from top-up health insurance paid for by their employer. This allows many women to choose both who follows their pregnancy (family doctor, obstetrician, midwife) and where they give birth: private clinic (often luxurious but not necessarily equipped to deal with an emergency), or public hospital (can deal with anything).

Any maternity unit handling more than 1,500 births a year is legally obliged to have a full medical team (paediatrician, obstetrician, anaesthetist, nurse, midwife) on duty 24 hours a day. New mothers are also pampered: even after a normal, uncomplicated birth, many will stay in the clinic for up to five days.

However, many women complain about an over-medicalisation of what should be a natural process. Health spending cuts have created shortages of both midwives (40% of hospitals have at least one midwife post vacant) and obstetricians, and led to the closure of nearly 20% of small maternity units.

Faced with a sharp increase in the number of high-risk pregnancies (notably premature and multiple births), the health minister, Philippe Douset-Blazy, recently unveiled a €270m (£187m) programme to modernise the whole maternity sector. The plan entails recruiting 500 extra midwives, 400 doctors and 1,300 nurses, as well as investing in more ambulances and modern reanimation equipment. Douste-Blazy also wants to see an obligatory consultation with both parents in the fourth month of pregnancy, and to develop a pilot project involving so-called maisons de naissance , where women can give birth in a less medicalised environment.Jon Henley

Germany

Germany has one of the best healthcare systems in the world, with an extensive network of hospitals and doctors covering even the most remote areas. Waiting lists are virtually non-existent. Medical facilities are equipped with the latest technology and a statutory health insurance scheme provides nearly full cover for most medical treatments and medicines.

Pregnant women, meanwhile, routinely receive examinations in the run-up to any birth, not from their local GP but from a specialist gynaecologist. All women are entitled to at least three ultrasounds - although 60% get more. Home births are extremely rare. The downside to all this is that births in Germany are highly medically managed, with women having little say. Afterwards, mothers get generous maternity provision, with either parent allowed to take up to three years off and return to their jobs.

Under the German system medical costs are high. Health care costs - for doctors, hospital stays and even medicines - are among the most expensive in the world. There is no such thing as "free" treatment in Germany, not even for emergencies, or for tragic cases such as that of Christoph Schwennicke and his wife Ulrike Weidner. Almost everybody in Germany, though, has access to the health care system, regardless of how much money they earn. Poor mothers are exempted from paying into Germany's national health insurance scheme. Richer German mums-to-be, meanwhile, can opt into the private system, though there appears to be little difference in treatment.

The reason for the success of German hospitals is not difficult to explain. Germany spends more money on its health service than Britain - 10.5% of its GDP, compared to only 7% in the UK.Luke Harding

Spain

"In the case of complications, partners will not normally be allowed in the birthing room," said the sign on the wall of the maternity ward. My wife was 12 hours into labour at one of Madrid's main public hospitals when I noticed it.

It wasn't the best time to take on Spain's notoriously intransigent bureaucracy, and thankfully I never had to. But the idea that when the going gets tough, dad will only get in the way typifies the approach to childbirth in Spain's public healthcare system.

It's an industrial process. The professionals involved are completely focussed on what the objective is. It doesn't occur to them to ask how the parents might like to get there or whether they could contribute anything more than a timely push. So while there is plenty of care available, it comes in one size to fit all. Any variations that do creep in tend to be decisions of the medical staff rather than the parents.

Pregnancy is managed by a midwife and a doctor through local health centres. Some GPs like to handle pregnancies themselves, others pass it on to a specialist gynaecologist. But it's up to the GP to decide rather than the mother.

When the big day comes, it's off to the local hospital, an enormous baby factory, where you are taken on by whichever team happens to be on duty. A common reason why people go private is to see the same midwife who has taken them through the pregnancy. The Spanish approach is certainly brutal. But it keeps things simple and effective.Ben Sills